I have just returned from a brief trip to Delhi. While there I met with the Planning Commission to talk about India’s nutrition situation, participated in the Britannia Nutrition Foundation’s third symposium and was on a panel (Malnutrition: Cracking the Code) of commentators organised by the NDTV channel.
Some reflections on the Planning Commission meeting:
While there is clearly a real concern within the Central Government about undernutrition and a desire to do something about it, my sense is that there is a lack of intensity and focus to the efforts and no real mechanism for mobilising all the available instruments (e.g. agriculture, sanitation, health systems, women’s empowerment, food programmes etc.) to deal with the issue. My presentation at the Planning Commission, chaired by the Deputy Chairman, precipitated a 70 minute dialogue among the 20 or so Commission members present. In a good natured discussion we touched on a number of issues:
• The interactions between the enabling environment for nutrition and the effectiveness of nutrition programmes like ICDS: if open defecation is practiced by over half of the population, if agricultural growth does not seem to drive nutrition improvements, if the health service is underfunded and if the women lack power then how can even the best nutrition programmes (or economic growth for that matter) get any traction in reducing undernutrition?
• The need for annual outcome data on undernutrition. The last assessment of nutrition status in India was in 2005-6. Can you imagine running an economic strategy in 2011 based on 2006 economic indicators? That is what is happening with nutrition. Apparently annual outcome data on nutrition will begin within a year or two.
• How the 12th 5 year plan (in development) will differ from the 11th when it comes to nutrition. Answers included: more funds for ICDS and more of a focus of that programme on the first 1000 days of life. Indeed, the whole 12th Plan will be health orientated.
• Was there something unique about India? Nutrition standards? Women’s status? Low diet diversity? On standards (are the healthy growth standards from other populations too high for Indians?) they may contribute to the high levels of undernutrition in South Asia relative to Sub Saharan Africa (Stephan Klasen has written about this) but standards would not be responsible for the slow rate of decline in undernutrition. On women’s status, yes, it is low in India, but it can be changed (look at the evidence from Duflo and others about the female quotas on Indian village council leadership showing that this form of empowerment increases nutrition relevant expenditures in the community). On diet, vegetarianism might be a challenge for raising the calorie density and micronutrient availability of diets, but there are many nutrition outcome bright spots within India that suggest these features of culture do not represent a binding constraint.
• Reassurances that a “nutrition lens” was being placed on other sectors (17 was the number mentioned) although I was less reassured about who within the Commission was going to make sure nutrition was firmly embedded within the 12th Plan.
• The need for the Government to commission the research it feels it needs. It does not at the moment. For instance the best study on ICDS impacts happens to be a PhD study by an Indian researcher at an American University—the Government got lucky, but it should be more demanding about the kinds of research it needs in order to do its business.
• While many members of the Commission clearly feel passionately about undernutrition, it does not seem to be anyone’s sole responsibility. I argued for more leadership from the Centre, mindful that a lot of power is devolved to the States, and for a strategic perspective on what to do about nutrition (there are so many opportunities, a strategic approach is needed) but I don’t think I was terribly persuasive.
Reflections on the Britannia Nutrition Foundation Symposium:
• The divide between public and private sectors in nutrition in India seems as large as ever. If the private sector is to be involved in shaping nutrition outcomes then the feeling from much (I think) of civil society is “they are only out for profit”. Well, guess what, they are already involved in shaping nutrition outcomes for profit. How can we begin talking to them to find and increase the overlaps between good profit outcomes and good nutrition outcomes? Part of the problem is, I suspect, an inability to know which companies are behaving responsibly and doing good things and which are not. At the moment we have to rely on what companies self report and even then in a rather piecemeal way. Accountability is weak. Marc van Ameringen the CEO of the Global Alliance for Nutrition (GAIN) reported on their work to assess the nutrition performance of food companies. I think this promises to be a great initiative (the candidate indicators are on the GAIN website www.gainhealth.org) because it will help us assess the reputation of a company in a more transparent way.
• There are dynamic States. Dr Veena Rao presented the Karnataka Nutrition “Mission”— a public commitment by the leadership of the State to place nutrition higher on the agenda and a commitment to spend more of the state’s money on nutrition in the hope that it will leverage additional funds from within and outside India. This whole initiative is quite inspirational—of course the implementation will be crucial if it is to live up to its aspirations.
• The lack of incentives for the Indian nutrition research community to reflect more holistically about the causes of the stagnation in nutrition status. Where are the demand driven research funds? Are the journals putting out calls for answers to these questions? Are the academic societies lobbying government via the media about nutrition? Are studies being done on how nutrition is shaped, framed, communicated and taught? Is there research on the beliefs and attitudes of key decision makers on nutrition, and on how the media report on nutrition and why? There are plenty of exceptions, and the level of nutrition science expertise is very high, but the lack of incentives to researchers to generate a wider system perspective is, I believe, a problem.
• The Britannia Nutrition Foundation is providing a service that other organisations should also be shouldering: annually convening Indian nutrition thinkers and leaders from a wide background to share innovations and findings, network, and strategise. Why is this not happening?
Reflections on the NDTV panel (airing on Sept 10):
• In addition to me the participants were Syeda Hameed, responsible for ICDS within the Planning Commission, Vinita Bali, the MD of Britannia and the Chair of the Foundation and a famous Indian screenwriter and activist. The moderator was a journalist from NDTV.
• Our moderator (excellent) told us that she had to study for a few days to get up to speed on undernutrition facts and consequences. She admitted to being shocked by what she read. This is a fascinating insight into the invisibility of the malnutrition issue.
• Other NDTV reporters in the audience noted that nutrition was not an electoral issue and that there were no “hooks” on which to put nutrition stories. We agreed that regular data on nutrition outcomes would be an important hook (and we all eagerly await the results of the Naandi Foundation’s first survey of the worst off districts—out later this year). I mentioned the work IDS has done in Peru, documenting how civil society groups in Peru (including CARE-Peru) forced electoral candidates to produce “malnutrition manifestos” – what they would do on undernutrition if they were elected. What a great commitment mechanism.
• Finally my trip came at the end of a two week hunger strike by the activist Anna Hazare in protest at the widespread corruption in Indian life (not so much paying for things citizens are not entitled to, but having to pay bribes for things citizens are entitled to, like a drivers licence, school entry, access to water etc). I made the point that it is ironic that civil society has been energized by a hunger strike, but that it cannot be energised by the hunger and malnutrition that pervades society.
I’m not suggesting hunger strikes to draw attention to malnutrition, but I wonder what the lessons of the Hazare movement will be for our collective efforts to generate energy around the need to reduce undernutrition in India?